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Tracheal Rupture Following Blunt Chest Trauma Presenting As Endotracheal Tube Obstruction Cynthia L

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Tracheal Rupture Following Blunt Chest Trauma Presenting As Endotracheal Tube Obstruction Cynthia L 816 Tracheal rupture following blunt chest trauma presenting as endotracheal tube obstruction Cynthia L. Henderson MD FRCPC, Scan R. Rose MD FRCPC In this report, we describe a patient in whom a tracheal tear In all trauma cases, basic rescucitation begins with the followed blunt thoracic trauma. 1he diagnosis was made late establishment and maintenance of an adequate airway. resulting in problems with ventilation, endotracheal tube ob- If blunt thoracic trauma has occurred, one should always struction and cardiac arrest. Difficulties with early recognition consider the possibility of concomitant tracheal injury. of tracheobronchiai injuries may be caused by non-specific find- Unfortunately, more common injuries associated with ings as well as the lack of exposure of physicians to patients trauma may produce similar findings and divert one's with these injuries. The signs and symptoms of tracheobronchial attention from the less frequent tracheobronchial trauma. injuries are described, as well as their differential diagnoses. The following case demomtrates the importance of a A review of airway management has been made as it requires high index of suspicion in making the diagnosis of tra- combined anaesthetic and surgical expertise. Injuries of the tra- cheobronchial injury following blunt trauma to the chest. chea may have severe, life-threatening consequences and early diagnosis and management reduce morbidity and mortality. Case report A 64-yr-old man was evaluated following blunt chest Cette observation d~crit I'~,volurion d'un patient victime d'une trauma. A hydraulic garbage container fell, crushing his d~chirure trach~ale d la suite dim traumatisme thoracique chest between the container and the ground. The patient fermd. Des probl~mes ventilatoire~, une obstruction de la canule and a co-worker lifted the container and the patient endotrach~ale et un arr~t cardiaque ont orient~ vers ce dia- walked home. He presented to the Emergency Depart- gnostic. La difficult~ de reconnattre prdcocement une blessure ment of a community hospital two hours later with trach~obronchique peut provenir aussi bien de ia non sp~cificit~ respiratory distress and hypotension. His trachea was des sympttmes que de l'exp~rience du mddecin qui traite ce intubated, intermittent positive-pressure ventilation com- type de blessure. Lea signes et sympttmes des blessures tra- menced and he received adrenaline. Bilateral chest tubes chd,obronchique$ sont d~taill~s ainsi que le diagnostic diffdren- were inserted because of the potential for tension pneu- tiel. On attire l'attention sur la gestion des voies a~riennes qui mothoraees. n~cessite autant de comp&ence de la part de l'anesthdsiste que After stabilization he was transferred and evaluated du chirurgien. Les blessures d la tmch~e peuvent avoir des r$per- by the Trauma Service. At that time, his blood pressure cussions graves et le diagnostic et une gestion prdcoces en r$dui- was low at 80/50 rnrnHg and femoral arterial and venous sent la morbidit~ et la mortaliM. lines were inserted for diagnosis and management. The portable chest x-ray taken on admission revealed a pneumomediastinum, bilateral multiple rib fractures, bilateral chest tubes with no pneumothoraces, and ex- Key words tensive subcutaneous emphysema along the chest wall. AIRWAY" obstruction; The endotracheal tube was in a good position. A Com- COMPLICATIONS: trauma; puter Assisted Tomography (CT) Scan in Emergency LONG: trachea, rupture. showed a large pneumomediastinum, subcutaneous air, From the Department of Anaesthesia, St. Paul's Hospital, and a right pneumothorax. The patient was transferred 1081 Burrard Street, Vancouver, B.C. VtZ IY6 and the to the Surgical Intensive Care Unit haemodynamically Department of Anaesthesia, Peace Arch Hospital, 15521 stable. On arrival, his blood pressure decreased to 80/ Russell Avenue, Whiteroek, B.C. V4B 2R6. 50 mmHg and a needle thoracostomy was performed Address correspondence to: Dr. Cynthia L. Henderson. followed by the insertion of two additional chest tubes. Acceptedfor publication 19th May, 1995. The patient's condition worsened and his oxygen satu- CAN J ANAESTH 1995 / 42:9 / pp Sl6-9 Henderson and Rose: TRACHEAL RUPTURE 817 ration decreased. His lungs became more difficult to ven- tilate and increased resistance was noted when manually ventilating them with an Ambu bag, ruling out problems with the mechanical ventilator. A suction catheter was passed easily down the endotracheal tube beyond the tip and a large blood clot was removed. His ventilation im- proved but his blood pressure decreased to 70 mmHg systolic and he developed electromechanical dissociation (EMD). CPR was initiated. Before the arrest, the patient had received 7 L crystalloid in the SICU and, thus, hy- povolaemia was not considered to have caused the EMD. The differential diagnosis included tension pneumothorax and pneumomediastinum, cardiac tamponade, myo- cardial contusion and hypoxia. Epinephrine 1 mg/v was given which increased the systolic blood pressure to 120 FIGURE CT scan showing endotracheal tube (arrow) outside the mmHg. Bronchoscopy was performed immediately and tracheal lumen. a tracheal tear was found. The endotracheal tube was inserted past the tear under direct vision and the patient's condition quickly stabS. The patient was transferred to the operating room or chest during motor vehicle accidents accounts for 80% where he was found to have an almost complete dis- of injuries to the larynx or the tracheobronchial tree 2 ruption of the distal trachea. The continuity of the trachea and early diagnosis and management reduce the mor- had been maintained by a 5 mm portion of membranous bidity and mortality from tracheobronchial tears.3-s Fol- trachea in the midline of the posterior tracheal wall. lowing non-penetrating trauma, other intrathoracic inju= Anaesthesia was maintained with isoflurane, opioids, and des are much. more common than tracheobronchial muscle relaxants using ,positive-pressure ventilation. At injuries. Delays in diagnosis may occur because the signs the level of the innominate artery, 3-0 Vicryl was used are non-specific and these injuries axe infrequent. in an interrupted fashion to suture the trachea. The endo- Clinical manifestations depend upon the location and tracheal tube was left in position with the cuff inflated extent of the tear as well as on the associated injuries. below the tear during the tracheal repair. Following the Nearly 10% of patients are asymptomatic but the majority repair, the endotracheal tube was pulled back until the present with dyspnoea, haemoptysis and/or cyanosis. ~ tip lay proximal to the suture line to miniunz"e pressure Other common symptoms may be subtle and include lo- on the repair site. cafized pain, hoarseness, coughing, difficultyswallowing Postoperatively the patient continued to have a stormy and stridor.Massive hacmopWsis indicates an associated course. The following day he had a traumatic false aneu- vascular injury and not an isolated tracheal or bronchial rysm of the aortic arch repaired which was found on injury,t Signs inchde bruising or swelling of the neck, review of the initial CT scan, The patient required tracheal deviation, abnormal breath sounds, tension positive-pressure ventilation for two weeks postoperatively pneumothorax, hypotension, cardiovascular collapse and due to rib fractures, pulmonary contusions and Adult Hamman's sign, a crunching sound synchronous with the Respiratory Distress Syndrome before being successfully heart beat.~ Subcutaneous emphysema is the most con- weaned from the ventilator. At the time of discharge from sistcnt physical finding,s Pneumopcritoncum, usually the Surgical Intensive Care Unit, the chest x-ray showed associated with perforation of a viscus, has been described an elevated left hemidiaphragm with bilateral plettral ef- rarely. 9 Acute symptoms may resolve with emergency fusions. He was discharged home 19 days post-injury with treatment only to return in days or weeks once stenosis no apparent sequelae. develops at the site of injury, to Our patient presented When the initial CT scan was reviewed, higher cuts with respiratory distress and hypotension of unknown ae- showed the endotracheal tube inside the traeheal lumen tiology. but, just above the carina, the distal tip was clearly out- Chest and neck x-rays are essential to verify an air side the lumen (Figure). leak and may reveal free air that is not detectable on physical examination. Cervical and thoracic subcutaneous Discussion emphysema are the most consis."tent radiological findings Traumatic injuries of the tracheobronchial tree range in tracheal injuries caused by blunt trauma; however, they from asymptomatic to fatal, i Blunt trauma to the neck are more commonly seen as nonspecific fmdings in the 818 CANADIAN JOURNAL OF ANAESTHESIA acute trauma patient after multiple rib fractures, pene- these patients. Direct laryngoscopy may cause further trating chest wounds, or a difficult intubation. H Subcu- deterioration in airway patency and intubation may result taneous emphysema that persists or increases should raise in the distal endotracheal tube lying outside the tracheal the suspicion of a continuing air leak from an airway lumen, as in this case. Preferably, intubation is performed injury, although disappearing emphysema does not rule using fibreoptic bronchoscopy as guidance to visualize out an airway tear. H Pneumomediastinum is an early the injury. If the tear involves the trachea, the cuff of diagnostic sign but may also
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